What is the best approach to evaluate and manage a 55-year-old female with dizziness?

From the Guidelines

The best approach to evaluate and manage a 55-year-old female with dizziness begins with a thorough history and physical examination to distinguish between vertigo, presyncope, disequilibrium, or lightheadedness. The clinician should assess for cardiovascular risk factors, medication side effects, and neurological symptoms. Initial evaluation should include vital signs, orthostatic blood pressure measurements, cardiovascular examination, and a focused neurological exam including the Dix-Hallpike maneuver to test for benign paroxysmal positional vertigo (BPPV) 1.

Key Considerations

• Laboratory testing should include complete blood count, basic metabolic panel, thyroid function tests, and blood glucose.
• If BPPV is diagnosed, the Epley maneuver can be performed in-office with success rates of 80% 1.
• For vestibular neuritis or labyrinthitis, symptomatic treatment with vestibular suppressants like meclizine 25mg every 6-8 hours for 3-5 days may help, though prolonged use should be avoided as it can delay central compensation 1.
• For Ménière's disease, a low-salt diet (less than 2g sodium daily) and diuretics like hydrochlorothiazide 25mg daily may be beneficial 1.
• Persistent or concerning symptoms warrant referral for specialized testing such as audiometry, videonystagmography, or brain imaging.
• Addressing underlying causes like hypertension, anemia, or medication side effects is essential for effective management.
• Vestibular rehabilitation therapy should be considered for patients with chronic dizziness to improve balance and reduce fall risk.

Differential Diagnosis

The differential diagnosis for dizziness is broad and includes various conditions such as BPPV, Ménière's disease, vestibular neuritis, labyrinthitis, and stroke/ischemia, among others 1. A thorough history and physical examination are crucial in distinguishing between these conditions and guiding further management.

Management Approach

A step-wise approach to management, starting with the least invasive and most likely cause, is recommended. This includes treating any underlying conditions, managing symptoms, and referring for specialized testing or therapy as needed. Patient education on the impact of their condition, potential for recurrence, and importance of follow-up is also crucial 1.

From the FDA Drug Label

The patient should be cautioned to report symptoms of supine hypertension immediately. Symptoms may include cardiac awareness, pounding in the ears, headache, blurred vision, etc. Patients who experience any signs or symptoms suggesting bradycardia (pulse slowing, increased dizziness, syncope, cardiac awareness) should be advised to discontinue midodrine and should be re-evaluated.

The best approach to evaluate and manage a 55-year-old female with dizziness is to:

• Monitor blood pressure regularly, especially when using midodrine concomitantly with other agents that cause vasoconstriction
• Assess renal and hepatic function prior to initiating therapy and subsequently, as appropriate
• Evaluate the patient for symptoms of supine hypertension and bradycardia
• Use midodrine with caution in patients with urinary retention problems, orthostatic hypotensive patients who are also diabetic, and those with a history of visual problems who are also taking fludrocortisone acetate 2
• Adjust the dose of midodrine according to the patient's response and renal function, with a starting dose of 2.5 mg in patients with renal impairment 2

From the Research

Evaluation Approach

To evaluate a 55-year-old female with dizziness, the following steps can be taken:

• Take a thorough medical history to identify any underlying conditions that may be contributing to the dizziness
• Perform a physical examination, including a neurologic examination and notation of any apparent anatomic abnormalities
• Consider orthostatic hypotension as a potential cause of dizziness, as it is a common phenomenon in older adults 3
• Use bedside tests such as the Dix-Hallpike test to diagnose benign paroxysmal positional vertigo (BPPV), a common cause of vertigo 4
• Consider the use of non-invasive continuous blood pressure monitoring to improve the sensitivity of the head-up tilt test (HUTT) in diagnosing orthostatic hypotension 5

Differential Diagnosis

The differential diagnosis for dizziness in a 55-year-old female includes:

• Orthostatic hypotension 3, 6, 5
• Benign paroxysmal positional vertigo (BPPV) 4, 5
• Vestibular dysfunction 6
• Cardiovascular disorders 3, 6
• Neurologic disorders 6, 5

Management

The management of dizziness in a 55-year-old female depends on the underlying cause:

• For orthostatic hypotension, treatment options include droxidopa, a synthetic oral norepinephrine prodrug, and midodrine 3
• For BPPV, treatment options include the Epley maneuver and vestibular suppressant medications 4
• For vestibular dysfunction, treatment options include vestibular rehabilitation therapy 6